www.scielo.br/jaos http://dx.doi.org/10.1590/1678-775720140110
Evaluation of technical quality and periapical KHDOWKRIURRW¿OOHGWHHWKE\XVLQJFRQHEHDP&7 Bilge Gülsüm NUR1, Evren OK2, Mustafa ALTUNSOY12VPDQ6DPL$ö/$5&,3, Mehmet ÇOLAK4, Enes GÜNGÖR4 'HSDUWPHQWRI3HGRGRQWLFV)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\,]PLU7XUNH\ 'HSDUWPHQWRI(QGRGRQWLFV)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\,]PLU7XUNH\ 'HSDUWPHQWRI2UDODQG0D[LOORIDFLDO5DGLRORJ\)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\,]PLU7XUNH\ 4- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Dicle University, Diyarbakir, Turkey. Corresponding address:%LOJH*OVP1XU'HSDUWPHQWRI3HDGLDWULF'HQWLVWU\)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\ø]PLU7XUNH\3KRQH 3434445/1725 - 0505 4421826 - Fax: +90 232 3435656 - e-mail: [email protected] 6XEPLWWHG $SULO0RGL¿FDWLRQ -XO\$FFHSWHG 6HSWHPEHU
ABSTRACT
O
EMHFWLYH 7KLVVWXG\DLPHGWRDVVHVVWKHTXDOLW\RIURRW¿OOLQJVFRURQDOUHVWRUDWLRQV FRPSOLFDWLRQV RI DOO URRW¿OOHG WHHWK DQG WKHLU DVVRFLDWLRQ ZLWK DSLFDO SHULRGRQWLWLV (AP) detected by cone-beam computed tomography (CBCT) images from an adult Turkish subpopulation. Material and Methods: The sample for this study consisted of 242 patients (aging from 15 to 72 years) with 522 endodontically treated teeth that were assessed for WHFKQLFDOTXDOLW\RIWKHURRWFDQDO¿OOLQJDQGSHULDSLFDOVWDWXVRIWKHWHHWK$GGLWLRQDOO\WKH DSLFDOVWDWXVRIHDFKURRW¿OOHGWRRWKZDVDVVHVVHGDFFRUGLQJWRWKHJHQGHUGHQWDODUFK WRRWKW\SHDQGDJHFODVVL¿FDWLRQXQGHWHFWHGFDQDOVLQVWUXPHQWIUDFWXUHURRWIUDFWXUH apical resorption, apical lesion, furcation lesion and type and quality of the coronal structure. Statistical analysis was performed using percentages and chi-square test. Results: The success rate of the root canal treatment was of 54.4%. The success rates of adequate DQG LQDGHTXDWH URRW FDQDO WUHDWPHQW ZHUH QRW VLJQL¿FDQWO\ GLIIHUHQW S! $SLFDO periodontitis was found in 228 (45.6%) teeth treated for root canals. Higher prevalence of AP was found in patients aging from 20 to 29 years [64 (27%) teeth] and in anterior (canines and incisors) teeth [97 (41%) teeth]. Conclusions: The technical quality of root FDQDO¿OOLQJSHUIRUPHGE\GHQWDOSUDFWLWLRQHUVLQD7XUNLVKVXESRSXODWLRQZDVFRQVLVWHQW with a high prevalence of AP. The probable reasons for this failure are multifactorial, and there may be a need for improved undergraduate education and postgraduate courses to improve the clinical skills of dental practitioners in endodontics. Keywords: Cone-beam computed tomography. Root canal. Apical periodontitis.
INTRODUCTION
cannot provide adequate information about the root canal configuration. Recently, cone-beam computed tomography (CBCT) is being widely used in dental practice and research. CBCT have been used to provide greater details about the root canal anatomy and their surrounding structures compared to radiographic images19. Follow-up studies on root canal treatment in educational hospitals, which have showed that the reality for the overall population might be somewhat different, present success rates between 35%96%14,20,21. A root canal treatment applied with the highest standards of care can heal the periapical lesion12. However, regardless of the population JURXS DQG JHRJUDSKLF ORFDWLRQ VWXGLHV FRQ¿UP that outcomes of root canal treatments performed
7KHTXDOLW\RIURRWFDQDO¿OOLQJVLVDVVRFLDWHGZLWK the adequate treatment of roots, which depends on their length in relation to the apex, homogeneity and quality and type of coronal restorations23,29. The successful interpretation of endodontic problems was associated with diagnostic imaging techniques that provide information about the teeth and their surrounding anatomy. Numerous studies have used periapical radiographs to assess the anatomic structure of teeth and to analyze the number and location of root canals23,29. However, periapical radiographs provide two-dimensional images, therefore, they
J Appl Oral Sci.
502
2014;22(6):502-8
(YDOXDWLRQRIWHFKQLFDOTXDOLW\DQGSHULDSLFDOKHDOWKRIURRW¿OOHGWHHWKE\XVLQJFRQHEHDP&7
1. Patients over 14 years old; 3DWLHQWVYLVLWLQJWKHFOLQLFIRUWKH¿UVWWLPH 3. CBCT images of good quality; 4. Previous root canal treatment performed by general practitioners. Exclusion criteria included the following: 1. CBCT images presenting deformations; 2. Unsatisfactory coronal restoration; 3. Recently traumatized and treated teeth; 4. Orthodontic patients. The CBCT images were obtained using a CBCT scanner (I-CAT Vision TM Imaging Science ,QWHUQDWLRQDO+DW¿HOG86$ DWN9S mA, with an exposure time of 8-9 s. The voxel size of the images was 0.3 mm. The acquisition process was performed by an experienced radiologist according to the recommendations of the manufacturer, with the minimum exposure necessary for adequate image quality. Intraexaminer calibration of the CBCT images was first performed to evaluate the reliability of the assessment. All images were assessed separately two times by two examiners (an endodontist and a maxillofacial radiologist) with a 2-week interval between the assessments. In the case of disagreements between the pair, these were discussed with another radiologist until a consensus was reached. The following factors were assessed in all images: sex, dental DUFKWRRWKW\SHDQGDJHFODVVL¿FDWLRQXQGHWHFWHG canals, instrument fracture, root fracture, apical resorption, apical lesion, furcation lesion, type DQGTXDOLW\RIWKHFRURQDOVWUXFWXUHDQGVXI¿FLHQW RYHU¿OOHG DQGLQVXI¿FLHQW XQGHU¿OOHG URRWFDQDO ¿OOLQJ 5) )LJXUH 7KH FULWHULD XVHG IRU WKH H[DPLQDWLRQ ZHUH VOLJKWO\ PRGL¿HG IURP WKRVH described by De Moor, et al.4 VXI¿FLHQW 5) ZDV GH¿QHG DV D URRW FDQDO VSDFH WKDW ZDV
by general dental practitioners show much lower success rates4,23,27,30. One of the most important reasons for such poor quality treatment is an increase in the prevalence of apical periodontitis (AP). The chronic inflammation of the periapical structure usually develops itself without the patient experiencing symptoms, thus, radiological examination is still fundamental for its detection. AP is generally underestimated and sometimes not detectable in panoramic and periapical radiographic images, because of the superposition of anatomical landmarks6. The main advantage of a 3D view of maxillofacial structures is that they have no superimpositions with anatomical landmarks15. Previous studies assessed the quality of root canal fillings by radiography 23,29. However, no studies have yet assessed the quality of root canal ¿OOLQJVXVLQJ&%&7LQD7XUNLVKVXESRSXODWLRQ7KLV study was aimed to assess the quality and periapical VWDWXV RI URRW FDQDO ¿OOLQJV E\ &%&7 LQ D 7XUNLVK subpopulation.
MATERIAL AND METHODS &%&7LPDJHVRIURRWFDQDO¿OOLQJVZHUHREWDLQHG from patients who first visited the Faculty of Dentistry of Dicle University, Diyarbakir, Turkey, between 2009 and 2011. We assessed a database of 522 CBCT scans of endodontically treated teeth obtained from 276 patients according to sex and age (15-72 years), and records of third molars were excluded. This study was based on a retrospective assessment of CBCT images and approved by the Medical Ethics Committee of ùifa University (Protocol #33-2013). The selection criteria included the following:
Figure 1-$( ,QVXI¿FLHQW XQGHU¿OOHG URRWFDQDO¿OOLQJ % XQGHWHFWHGFDQDOV &* $SLFDOOHVLRQ ) 2YHU¿OOHGURRW¿OOLQJ DQGLQVWUXPHQWIUDFWXUH, $SLFDOUHVRUSWLRQ+- 6XI¿FLHQWURRW¿OOLQJ J Appl Oral Sci.
503
2014;22(6):502-8
185%*2.($/781620.05). The distribution frequency of the AP affected the maxillae [168 teeth (45.4%)] and mandible [70 teeth (46%)] in the dental arch was similar. There were found 238 (45%) AP lesions. The AP lesions were located most frequently in maxillary incisors and canines [80 (15.3%) teeth], followed by maxillary premolars [50 (9.6%) teeth] and maxillary molars [38 (7.3%) teeth]. The AP lesions were located less frequently in mandibular incisors and canines [17 (3.3%) teeth]. In addition, without considering the technical quality of root canal treatments, the prevalence of apical health and coronal structure of the teeth showed no statistically VLJQL¿FDQW GLIIHUHQFH S! $Q DVVHVVPHQW of the coronal structure of the teeth with root FDQDO ¿OOLQJV UHYHDOHG WKDW KDG FRURQDO restorations, whereas 38.1% had been crowned. The relationship between the periapical status
FRPSOHWHO\¿OOHGHQGLQJ±PPIURPWKHDSH[ DQGZLWKQRYRLGV LQVXI¿FLHQW5)ZDVGH¿QHGDVD root canal space that was poorly condensed, ending more than 2 mm from the apex, and with voids. Additionally, the quality of coronal restoration was assessed according to any permanent restoration, radiographic signs of recurrent caries, open margins or presence of temporary coronal restorations or no restoration (Figure 2).
Statistical analysis The CBCT images used to assess the technical TXDOLW\ RI URRW FDQDO ¿OOLQJV ZHUH DQDO\]HG XVLQJ the chi-square test (p
Evaluation of technical quality and periapical KHDOWKRIURRW¿OOHGWHHWKE\XVLQJFRQHEHDP&7 Bilge Gülsüm NUR1, Evren OK2, Mustafa ALTUNSOY12VPDQ6DPL$ö/$5&,3, Mehmet ÇOLAK4, Enes GÜNGÖR4 'HSDUWPHQWRI3HGRGRQWLFV)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\,]PLU7XUNH\ 'HSDUWPHQWRI(QGRGRQWLFV)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\,]PLU7XUNH\ 'HSDUWPHQWRI2UDODQG0D[LOORIDFLDO5DGLRORJ\)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\,]PLU7XUNH\ 4- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Dicle University, Diyarbakir, Turkey. Corresponding address:%LOJH*OVP1XU'HSDUWPHQWRI3HDGLDWULF'HQWLVWU\)DFXOW\RI'HQWLVWU\ùLID8QLYHUVLW\ø]PLU7XUNH\3KRQH 3434445/1725 - 0505 4421826 - Fax: +90 232 3435656 - e-mail: [email protected] 6XEPLWWHG $SULO0RGL¿FDWLRQ -XO\$FFHSWHG 6HSWHPEHU
ABSTRACT
O
EMHFWLYH 7KLVVWXG\DLPHGWRDVVHVVWKHTXDOLW\RIURRW¿OOLQJVFRURQDOUHVWRUDWLRQV FRPSOLFDWLRQV RI DOO URRW¿OOHG WHHWK DQG WKHLU DVVRFLDWLRQ ZLWK DSLFDO SHULRGRQWLWLV (AP) detected by cone-beam computed tomography (CBCT) images from an adult Turkish subpopulation. Material and Methods: The sample for this study consisted of 242 patients (aging from 15 to 72 years) with 522 endodontically treated teeth that were assessed for WHFKQLFDOTXDOLW\RIWKHURRWFDQDO¿OOLQJDQGSHULDSLFDOVWDWXVRIWKHWHHWK$GGLWLRQDOO\WKH DSLFDOVWDWXVRIHDFKURRW¿OOHGWRRWKZDVDVVHVVHGDFFRUGLQJWRWKHJHQGHUGHQWDODUFK WRRWKW\SHDQGDJHFODVVL¿FDWLRQXQGHWHFWHGFDQDOVLQVWUXPHQWIUDFWXUHURRWIUDFWXUH apical resorption, apical lesion, furcation lesion and type and quality of the coronal structure. Statistical analysis was performed using percentages and chi-square test. Results: The success rate of the root canal treatment was of 54.4%. The success rates of adequate DQG LQDGHTXDWH URRW FDQDO WUHDWPHQW ZHUH QRW VLJQL¿FDQWO\ GLIIHUHQW S! $SLFDO periodontitis was found in 228 (45.6%) teeth treated for root canals. Higher prevalence of AP was found in patients aging from 20 to 29 years [64 (27%) teeth] and in anterior (canines and incisors) teeth [97 (41%) teeth]. Conclusions: The technical quality of root FDQDO¿OOLQJSHUIRUPHGE\GHQWDOSUDFWLWLRQHUVLQD7XUNLVKVXESRSXODWLRQZDVFRQVLVWHQW with a high prevalence of AP. The probable reasons for this failure are multifactorial, and there may be a need for improved undergraduate education and postgraduate courses to improve the clinical skills of dental practitioners in endodontics. Keywords: Cone-beam computed tomography. Root canal. Apical periodontitis.
INTRODUCTION
cannot provide adequate information about the root canal configuration. Recently, cone-beam computed tomography (CBCT) is being widely used in dental practice and research. CBCT have been used to provide greater details about the root canal anatomy and their surrounding structures compared to radiographic images19. Follow-up studies on root canal treatment in educational hospitals, which have showed that the reality for the overall population might be somewhat different, present success rates between 35%96%14,20,21. A root canal treatment applied with the highest standards of care can heal the periapical lesion12. However, regardless of the population JURXS DQG JHRJUDSKLF ORFDWLRQ VWXGLHV FRQ¿UP that outcomes of root canal treatments performed
7KHTXDOLW\RIURRWFDQDO¿OOLQJVLVDVVRFLDWHGZLWK the adequate treatment of roots, which depends on their length in relation to the apex, homogeneity and quality and type of coronal restorations23,29. The successful interpretation of endodontic problems was associated with diagnostic imaging techniques that provide information about the teeth and their surrounding anatomy. Numerous studies have used periapical radiographs to assess the anatomic structure of teeth and to analyze the number and location of root canals23,29. However, periapical radiographs provide two-dimensional images, therefore, they
J Appl Oral Sci.
502
2014;22(6):502-8
(YDOXDWLRQRIWHFKQLFDOTXDOLW\DQGSHULDSLFDOKHDOWKRIURRW¿OOHGWHHWKE\XVLQJFRQHEHDP&7
1. Patients over 14 years old; 3DWLHQWVYLVLWLQJWKHFOLQLFIRUWKH¿UVWWLPH 3. CBCT images of good quality; 4. Previous root canal treatment performed by general practitioners. Exclusion criteria included the following: 1. CBCT images presenting deformations; 2. Unsatisfactory coronal restoration; 3. Recently traumatized and treated teeth; 4. Orthodontic patients. The CBCT images were obtained using a CBCT scanner (I-CAT Vision TM Imaging Science ,QWHUQDWLRQDO+DW¿HOG86$ DWN9S mA, with an exposure time of 8-9 s. The voxel size of the images was 0.3 mm. The acquisition process was performed by an experienced radiologist according to the recommendations of the manufacturer, with the minimum exposure necessary for adequate image quality. Intraexaminer calibration of the CBCT images was first performed to evaluate the reliability of the assessment. All images were assessed separately two times by two examiners (an endodontist and a maxillofacial radiologist) with a 2-week interval between the assessments. In the case of disagreements between the pair, these were discussed with another radiologist until a consensus was reached. The following factors were assessed in all images: sex, dental DUFKWRRWKW\SHDQGDJHFODVVL¿FDWLRQXQGHWHFWHG canals, instrument fracture, root fracture, apical resorption, apical lesion, furcation lesion, type DQGTXDOLW\RIWKHFRURQDOVWUXFWXUHDQGVXI¿FLHQW RYHU¿OOHG DQGLQVXI¿FLHQW XQGHU¿OOHG URRWFDQDO ¿OOLQJ 5) )LJXUH 7KH FULWHULD XVHG IRU WKH H[DPLQDWLRQ ZHUH VOLJKWO\ PRGL¿HG IURP WKRVH described by De Moor, et al.4 VXI¿FLHQW 5) ZDV GH¿QHG DV D URRW FDQDO VSDFH WKDW ZDV
by general dental practitioners show much lower success rates4,23,27,30. One of the most important reasons for such poor quality treatment is an increase in the prevalence of apical periodontitis (AP). The chronic inflammation of the periapical structure usually develops itself without the patient experiencing symptoms, thus, radiological examination is still fundamental for its detection. AP is generally underestimated and sometimes not detectable in panoramic and periapical radiographic images, because of the superposition of anatomical landmarks6. The main advantage of a 3D view of maxillofacial structures is that they have no superimpositions with anatomical landmarks15. Previous studies assessed the quality of root canal fillings by radiography 23,29. However, no studies have yet assessed the quality of root canal ¿OOLQJVXVLQJ&%&7LQD7XUNLVKVXESRSXODWLRQ7KLV study was aimed to assess the quality and periapical VWDWXV RI URRW FDQDO ¿OOLQJV E\ &%&7 LQ D 7XUNLVK subpopulation.
MATERIAL AND METHODS &%&7LPDJHVRIURRWFDQDO¿OOLQJVZHUHREWDLQHG from patients who first visited the Faculty of Dentistry of Dicle University, Diyarbakir, Turkey, between 2009 and 2011. We assessed a database of 522 CBCT scans of endodontically treated teeth obtained from 276 patients according to sex and age (15-72 years), and records of third molars were excluded. This study was based on a retrospective assessment of CBCT images and approved by the Medical Ethics Committee of ùifa University (Protocol #33-2013). The selection criteria included the following:
Figure 1-$( ,QVXI¿FLHQW XQGHU¿OOHG URRWFDQDO¿OOLQJ % XQGHWHFWHGFDQDOV &* $SLFDOOHVLRQ ) 2YHU¿OOHGURRW¿OOLQJ DQGLQVWUXPHQWIUDFWXUH, $SLFDOUHVRUSWLRQ+- 6XI¿FLHQWURRW¿OOLQJ J Appl Oral Sci.
503
2014;22(6):502-8
185%*2.($/781620.05). The distribution frequency of the AP affected the maxillae [168 teeth (45.4%)] and mandible [70 teeth (46%)] in the dental arch was similar. There were found 238 (45%) AP lesions. The AP lesions were located most frequently in maxillary incisors and canines [80 (15.3%) teeth], followed by maxillary premolars [50 (9.6%) teeth] and maxillary molars [38 (7.3%) teeth]. The AP lesions were located less frequently in mandibular incisors and canines [17 (3.3%) teeth]. In addition, without considering the technical quality of root canal treatments, the prevalence of apical health and coronal structure of the teeth showed no statistically VLJQL¿FDQW GLIIHUHQFH S! $Q DVVHVVPHQW of the coronal structure of the teeth with root FDQDO ¿OOLQJV UHYHDOHG WKDW KDG FRURQDO restorations, whereas 38.1% had been crowned. The relationship between the periapical status
FRPSOHWHO\¿OOHGHQGLQJ±PPIURPWKHDSH[ DQGZLWKQRYRLGV LQVXI¿FLHQW5)ZDVGH¿QHGDVD root canal space that was poorly condensed, ending more than 2 mm from the apex, and with voids. Additionally, the quality of coronal restoration was assessed according to any permanent restoration, radiographic signs of recurrent caries, open margins or presence of temporary coronal restorations or no restoration (Figure 2).
Statistical analysis The CBCT images used to assess the technical TXDOLW\ RI URRW FDQDO ¿OOLQJV ZHUH DQDO\]HG XVLQJ the chi-square test (p
